HESI RN
HESI 799 RN Exit Exam Capstone Questions
Question 1 of 5
A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?
Correct Answer: C
Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.
Question 2 of 5
During an excretory urogram, which observation made by the nurse indicates a complication?
Correct Answer: B
Rationale: The correct answer is B because a whole-body bright red color indicates a severe reaction to the contrast dye and must be addressed immediately. Choices A, C, and D do not indicate a severe complication during an excretory urogram. Choice A is a common side effect of the dye, choice C could be a normal sensation due to the injection, and choice D may indicate nausea which is less severe compared to a whole-body red color reaction.
Question 3 of 5
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
Correct Answer: B
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.
Question 4 of 5
A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?
Correct Answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.
Question 5 of 5
A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?
Correct Answer: B
Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.
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